Coffee with an Elder Law Attorney "*" indicates required fields Step 1 of 3 33% Today's Date MM slash DD slash YYYY Birthday * Required MM slash DD slash YYYY Enter required information below. * Required First Last Email * Required Phone * RequiredResidence County * RequiredBentonWashingtonMadisonBaxterBooneCarrollIzardMarionNewtonSearcyStoneotherProfession * RequiredPublic/CommunityDieticianMedical StudentNursingNursing Home AdministrationParaprofessionalPatientPhysical TherapyPhysicianResidentSocial WorkStudentGender * RequiredMaleFemaleOtherRace * RequiredAfrican-AmericanAmerican IndianAsian/Pacific IslanderCaucasianHispanicMiddle EasternOtherHow did you learn of this program?(check all that apply) Facebook Website Word of Mouth My Center on Aging (the Schmieding Center) My Healthcare Provider (e.g., doctor, nurse, etc.) Other CONSENT TO USE MEDIA IMAGES FOR PROMOTIONS I hereby give the University of Arkansas for Medical Sciences, their legal representative, assigns, and those acting on their behalf and with their permission, the right and permission to copyright in any part of the world, to use, reuse, publish and republish, in conjunction with my own or fictitious name, any photograph, film or video tape recording taken of me by the University of Arkansas for Medical Sciences or those acting on their behalf or with their permission, and any reproductions thereof, in any form, whether intentional or otherwise, and may be used in conjunction with any advertising material, for any purposes of trade, advertising, exhibit, publicity, or promotion, without restriction or limitations. I understand that the photographs, film and/or video may be used in news releases, newspapers or magazine articles, television, the UAMS website or social media sites (e.g., Facebook , YouTube). I hereby release, discharge, and agree to save harmless the University of Arkansas for Medical Sciences, their assigns, legal representatives, agents, and those acting on their behalf and with their permission, from and against any liability resulting from any distortion, blurring, alteration or use in composite form, whether such was intentional or otherwise, which my occur, result, or be produced in the taking of said photography, or by processing or reproduction of the finished product, its publication or the distribution of same. I waive the right to approve or inspect the recordings, advertising copy, or material used in conjunction therewith.I consent, per above terms, to the use of my image by UAMS for program and event promotion * Required Yes No I want to receive email notice about other Schmieding Center events * Required Yes No Survey data is required by our funder to offer this program at no cost to participants. Only aggregate (group) data from this survey is reported.Which choice best describes my knowledge of the legal and financial plans I need to put into place for myself or my loved one. * Required Excellent Good Fair Poor SCSHE Which choice best describes my understanding of how to put elder law legal and financial plans into place. * Required Excellent Good Fair Poor SCSHE How would you rate your confidence in managing your legal affairs or those of a loved one? * Required Excellent Good Fair Poor SCSHE How would you rate your understanding of where to access resources to help plan for your future or that of your loved one? * Required Excellent Good Fair Poor SCSHE How would you rate your confidence in making a legal plan for getting older? * Required Excellent Good Fair Poor SCSHE